Triage in the rubble

When the streets of Gaza began filling with blood, there was only one place to take the wounded - Al Shifa Hospital, where ill-equiped doctors were working tirelessly to save lives.

The rubble of destroyed buildings adjacent to the house of senior Hamas militant Nizal Rayyan.

AL SHIFA HOSPITAL, Gaza City // Just before midday last Saturday, as schools were finishing for the day and Palestinians shopped in the crowded, if somewhat barren, markets in central Gaza City, Israeli F16s broke the sound barrier and unleashed a deadly payload of bombs on the coastal enclave. At the Al Shifa Hospital, Dr Ahmad Kandeel, who heads the surgery department, was tidying up some paperwork as he prepared for the 2pm shift change.

"After six months of a ceasefire, it had been quiet for us," he recalled. "Because of the blockade, we were very low on medical supplies and equipment, power cuts had limited our ability to do surgery, but things were normal. But it had been a little quiet for months." That shift change never came. For six straight days, Dr Kandeel joined his colleagues in struggling to treat the waves of casualties carried in on stretchers and in the arms of their grieving families, as Israeli air strikes pummelled the strip.

"The world exploded and turned to hell," said one Gaza resident, recounting how rockets, bombs and missiles landed amid various buildings and compounds related to the militant Islamic movement Hamas. Since it was a working day in Gaza, hundreds of Hamas members - police officers, militants and political leaders - were going about their regular business as the dominant political faction after seizing power from Fatah in a bloody coup during the summer of 2007. It meant the Israeli military was able to exploit the militant group's transformation from underground insurgents to a public presence, by bombing ministries and other government buildings.

More than 150 people died in the first 10 minutes, most of them uniformed Hamas members associated with the police force. But even as most of the strikes found their targets, the crowded streets of schoolchildren, shoppers and commuters were torn by shrapnel from the dozens of explosions that seemed to come without warning. More than 50 strikes were reported in Gaza in that first hour. As the Hamas security compounds filled with bodies of fighters, the surrounding streets filled with the blood of hundreds of wounded civilians.

In Gaza City, there was only one place to take them: Al Shifa Hospital with its six operating theatres. Taxis, ambulances, military vehicles and even private cars came carrying the casualties, including women and children, some of whom had been crushed by bricks when their flimsily built houses collapsed in the force of explosions. After a decade of saving lives with trauma medicine, Dr Kandeel realised there was no way his team could adequately handle even that first wave of injured.

"We immediately knew we would need more than six rooms for operations, so we began to force sick patients to leave and convert rooms," he said. "These places are not meant for surgery, but no hospital in the world was prepared for this situation. No one could have handled it." Within five minutes, doctors later recalled, the lobby of the building was full of wounded, dead and dying. After 10 minutes, the pavement outside had been converted to a triage centre to determine which of the wounded should be treated first, with an emphasis on those who could be saved.

Dr Awad Abu Hassan, another surgeon, said there was mass confusion as medical staff tried to treat the injured even as they scanned the bloody faces for signs of their own families. "We started to help and save as many people as we could and sometimes we took a very quick look at the injured and sent them to the operation room," he said. "Sometimes we diagnosed them during the surgery to save their lives, but so many people had complex injuries in multiple places; the same person might have suffered from more than one wound in his body, many had compound fractures and burns. This forced us to do more than 10 operations at the same time on the same person by different specialists."

Within the hour, the entire car park was full of patients, the wounded directed to the right and the dead to the left. Bodies were lined up across the car park and left for families to identify. Armed Hamas fighters, covered in dust and the blood of their comrades, dropped body after body on to the pile, or dragged their wounded as far into the hospital as they could. Dr Doran al Hatto was at home, about to eat lunch before his shift started at 2pm, on the day Israel launched Operation Cast Lead. A cardiothoracic surgeon, he immediately sprinted to the hospital in anticipation of casualties. What he saw there stunned him.

"I arrived at the same time as the first wounded came, but I had passed car after car full of wounded and martyrs, so I knew what had happened," he said, while tending to patients on Thursday morning. "I didn't even make it inside the hospital for an hour. We had run out of beds even before most of the wounded arrived, so I just began operating on people as they lie on the ground outside. No medicine, no anaesthesia, just my scalpel and one pair of gloves. I couldn't think; I just kept cutting and hoping I didn't find a relative of mine on the ground."

As the doctors tried to keep pace with the steady stream of injured, families scoured the halls and the car park looking for their missing loved ones. Mohammed Abdel Kareem, 23, a member of the Hamas police force, was killed on the first day. His family spent two days peering at the faces of the injured, and dead, at Al Shifa hoping and yet fearing they would find him. It was only when his 18-year-old wife described a birthmark on his leg, that the family was able to identify part of a badly burnt torso and legs. They never found his head or arms.

As the days wore on and Israel showed no let up in its relentless bombing campaign, and with medical supplies - already inadequate due to the crippling blockade that has left the strip perilously short of basic necessities - running low, doctors began triage: deciding who should be treated, and who should be left to die. But according to doctors, it was unrealistic for any hospital to handle almost 1,000 victims of severe trauma in the course of several hours with the supplies on hand. By yesterday afternoon, more than 420 people had been killed and 2,000 wounded across Gaza.

"No hospital has enough of these supplies to handle what we face," said Dr Hassan. "Even in America, they could not be ready for this." Israel allowed lorry-loads of aid into the strip on Wednesday and Thursday, even as it stepped up its air strikes, and moved tanks and soldiers to the border in anticipation of a ground invasion. But according to the hospital, the aid that Al Shifa has received so far - staples such as bandages, insulin and baby formula - are not needed to treat trauma patients.

"What we got from the international aid, we don't need them in this situation," Dr Hassan said. "There are some others things that are very important to us and we use them a lot such as pain killers, narcotics, antibiotics, surgical gloves, alcohol and disinfectant, saline solution, gauze, plasma, anaesthetic agents, plaster-cotton wraps, cut kits, chest tubes, and if we don't get all these things soon, we will suffer from overall deficit."

Tzipi Livni, Israel's foreign minister, who was campaigning for prime minister in Tel Aviv on Wednesday, said Israel puts no conditions on the type of medical supplies that enter Gaza. "The Israeli military let the trucks pass the crossing and checks them for security, but not for the type of supplies on them," she said. "The contents are the responsibility of the aid groups sending them. We have nothing to do with it."

International aid organisations said they have requested appropriate supplies and are aware of the situation but that logistics and decisions by donors often are out of their control. "Our stockpiles on hand were not intended for mass casualties," said one aid worker, who requested anonymity so as not to alienate donor nations. "No one anticipated this situation and we are at the mercy of what people actually send us. But no one has trauma supplies on hand to treat 1,700 wounded people in six days. Except maybe the Americans in Baghdad, but even them ? I just don't know."

While Israel claims its missile strikes target Hamas installations only, the reality on the ground tells a different story, with entire streets and compounds turned into rubble and ash. For Dr Hassan, who has not been home since Saturday and whose wife and five children live near a security compound that has been repeatedly targeted, it is a constant reminder that no one is safe. Al Shifa has already lost one doctor after he realised that he was treating his own family for grievous wounds.

"He can't work anymore," Dr Hassan said. "I am a father and live very close to one of the security places which has been attacked by planes while I am at work. "I am very afraid about my family but because it is my duty to save souls, I continue my work. It is possible I may save one of my family." * With additional reporting from Tsur Shezaf in Tel Aviv